We apply for funding for an R18 study in response to AHRQ's RFA-HS-10-002, Transforming Primary Care Practice. While leading professional societies have identified principles for restructuring primary health care in the Patient Centered Medical Homes (PCMH), the PCMH model remains largely an aspiration. The Palo Alto Medical Foundation (PAMF) is a large physician-led nonprofit multispecialty ambulatory care system in Northern California and an ideal setting to conduct a rigorous study of on-going, successful efforts to transform primary care delivery. First, PAMF has been implementing components of PCMH since 1999 and all three of PAMF's divisions have been certified by NCQA's Physician Practice Connection as Patient-Centered Medical Homes since 2006. Second, being a large multi-specialty practice with a multitude of payers and hang physicians whose compensation reflects FFS incentives make lessons from PAMF applicable to a wide range of health care delivery settings. Third, the diversity of PAMF in terms of practice size (from 3 to 300 physicians), payer mix (30% capitation and 70% fee-for-service), culture, location, and heterogeneous patient population provide the variability one needs to assess the effects of interventions. All PAMF clinics use the same EpicCare Electronic Health Record (EHR) allowing uniform assessments across sites. Finally, the PAMF Research Institute has a team of experienced investigators with direct access to data, medical leadership, and patients, yet freedom to publish all findings. In this project, we will obtain robust and detailed information about the actual primary care transformation processes - retrospective and concurrent - and the lessons learned by PAMF in its successful endeavors to transform primary care. The specific aims are to: (1) describe methods used to transform practices, with attention to the organizational context and culture and conditions within which changes have occurred. We will perform in-depth key informant interviews with decision makers at different levels of the organization including senior executives, quality improvement committee members, and frontline care team members including physicians and nurses. Qualitative data collection and analysis will follow the Grounded Theory approach. (2) Assess the changes in processes (e.g., same day appointments), intermediate clinical outcomes (e.g., blood pressure, HbA1c, and lipids for diabetes patients), and costs and efficiency of care (e.g., inpatient readmissions, emergency department visits, effective "panel" size that accounts for differences in patient need). Empirical approaches range from key informant interviews, focus group, to a retrospective quantitative quasi-experimental study with data drawn from EpicCare EHR, IDX scheduling, and billings data. (3) Determine the impact of the transformative processes on the actual experiences and satisfaction of physicians, staff, and patients. Key informant interviews and focus groups data collected for this study will be leveraged with routinely collected past and ongoing surveys undertaken by the organization. Insights learned from PAMF will inform future PCMHs elsewhere and policy makers in need of empirical evidence in developing PCMH payment and administrative policies. PUBLIC HEALTH RELEVANCE: Leading medical professional societies have identified Patient Centered Medical Homes (PCMH) as a key to revive primary care in the United States, even though the PCMH model remains largely an aspiration nation- wide. The Palo Alto Medical Foundation (PAMF) is a large physician-led nonprofit multispecialty ambulatory care system in Northern California and an ideal setting to conduct the proposed study. Researchers will use robust and detailed qualitative and quantitative information about the actual primary care transformation processes - retrospective and concurrent - and the lessons learned by PAMF in its successful endeavors to transform primary care. Insights learned from the study will inform future PCMHs elsewhere and policy makers in need of empirical evidence in developing PCMH payment and administrative policies.